Home For Providers Provider Manual Introduction

Introduction

• Welcome to Community Health Plan
• Who We Are
• Your Role as a Community Health Plan Provider

Welcome to Community Health Plan

We are pleased you have chosen to participate in our network of dedicated providers and share in our organization’s commitment to provide quality care for individuals and families who traditionally face barriers to the care they need. We look forward to supporting you as a Community Health Plan provider.

The Community Health Plan Provider Manual will serve as a reference for you as a provider and contains content such as:

• Introduction and who we are (this page)
• Directory of services and contacts
• Access to care standards
• Credentialing
• Access to records and enrollee health information
• Medical record documentation standards and policies
• Reporting changes in provider status
• Eligibility
• PCP assignment
• Disenrollment
• ID cards
• Enrollee benefits
• Children First™
• Enrollee rights and responsibilities
• Interpreter services
• Billing and claims payment
• Appeals
• DRG and fee schedule disputes
• Utilization management
  • Referrals
  • Prior authorizations
  • Hospital inpatient notification
  • Concurrent review
  • Discharge planning
  • Emergency room care
  • PEC review
• Case management
  • Referrals
• Member Review and Intervention Program (MRIP)
• Disease management
• Clinical care criteria
• Transition of care
• Pharmacy management
  • Formulary
  • Prior authorization, step therapy, nonformulary, and quantity override requests
  • Benefit exclusions
• Quality program

If you have questions regarding any policies and procedures explained in this manual, please contact our Provider Relations team: Phone 1-800-440-1561 toll free or fax 206-613-5018.

Who We Are

Community Health Network of Washington (CHNW) was formed in 1992 by a group of community health centers dedicated to a mission of providing accessible health care. Through its role as a delivery system for insured enrollees of Community Health Plan, the PLan comprises approximately 1,600 primary care providers and 8,000 specialists at more than 300 primary care sites and more than 90 hospitals. The Plan is strengthened by the shared commitment of its providers to deliver accessible managed care that meets the needs and improves the health of our communities.

Created by CHNW, Community Health Plan serves more than 236,000 insured enrollees statewide. As one of the largest providers of the state’s health plans, Community Health Plan offers affordable health insurance coverage through public programs including Healthy Options,  the Children’s Health Insurance Program (CHIP), Basic Health, Washington Health Program, Disability Lifeline, and Medicare Advantage.

One feature that distinguishes Community Health Plan from other health care networks is the commitment to providing a medical home for its patients, which results in individualized care. Through the dedication of community health centers and our contracted providers, Community Health Plan is able to establish a closer connection to our customers. This connection helps improve communication and the potential for better clinical outcomes. Families and individuals covered through the state insurance programs often require a broader spectrum of services, such as transportation and interpreter services. When possible, Community Health Plan providers have been committed to meeting these special needs.

Your Role as a Community Health Plan Provider

As a Community Health Plan provider, you have agreed to provide care to enrollees of Community Health Plan. We look forward to supporting you in providing accessible, quality health care that meets the needs your patients—our enrollees. A description of benefits and compensation extended to you are detailed in your provider agreement, in this provider manual and referenced policies and procedures.